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Q1,AHIry.• T <br />�a•.� SAN JOAQUIN COUNTY <br />S A <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />�it;pdk�, Telephone: (209) 468-3420 Fax: (209) 464-0138 Web: www.sicehd.com <br />COTTAGE FOOD OPERATIONS (CFO) <br />REGISTRATION/PERMITTING FORM <br />(CALIFORNIA HOMEMADE FOOD ACT AB 1616 (GATTO)) <br />CFO Business Name: Owner Name: Date: f013v/202'L <br />S+IKEE KITCHEN LLC- CIEETNA KAL/)C47 <br />CFO Physical Address: CFO City: CFO Zip: <br />I499 S PERICINS' PL- MouNrstlN 44;30 -RE 95391 <br />Website (If applicable): Telephone: <br />gob- css- 6929 <br />1. Categories: <br />® "Class A" (Direct Sales Only) $186 ❑ "Class B" (Direct & Indirect Sales) $312 <br />2. Prohibited Items: Initial if you agree to abide by the following: U. <br />Foods containing cream, custard, or meat fillings are potentially hazardous and are NOT ALLOWED. <br />Only foods that are defined as "non -potentially hazardous" are approved for preparation by a Cottage Food <br />Operation. These foods include items that do not require refrigeration to keep them safe from bacterial <br />growth that could be a cause of food-bome illness. <br />3. "Class A" Self Certification Checklist: <br />lto Checklist completed ("Class A" CFOs Only) <br />4. <br />Products: <br />Please check the items you will be preparing and/or selling. <br />[IBaked <br />Goods ElDried <br />Pasta <br />ElHoney <br />ElPopcorn/ <br />Popcorn Balls <br />❑ <br />Candy ❑ <br />Dry Baking Mixes <br />❑ <br />Mustard <br />❑ <br />Vinegar <br />❑ <br />Churros ❑ <br />Waffle Cones <br />❑ <br />Dried Grain Mixes <br />❑ <br />Fruit Butter** <br />ElFrosting/Icing* <br />Buttercream <br />El <br />Buttercream <br />El El <br />Flat Icing <br />El <br />Ground <br />Ground <br />❑ <br />Dried Mole Paste ® <br />Herb/Spice Blends <br />❑ <br />Pizzeles <br />❑ <br />Jams/Jellies** <br />ElFruit <br />Empanadas ElFruit <br />Tamales/Pies <br />ElButters <br />Nut Mixes/Nut <br />El <br />Fried or Baked <br />Donuts and <br />Waffles <br />❑ <br />Granola/Cereals ❑ <br />Seasoning Salt <br />❑ <br />Trail Mix/ Dried Fruit <br />❑ <br />Dried Fruit <br />El <br />Cotton Candy El <br />Candied Apples <br />❑ <br />Salted <br />ElBa�hmallow <br />Marshmallows/ <br />Caramel/Fudge <br />EHD <br />16-27 6/27/22 <br />1 <br />CFO REG/PERMITTING FORM <br />